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My last post on hip pain suggests the need for us all to be educated healthcare consumers and takes us back to the original goal of this blog – to be a credible, unbiased (by selling, advertizing or marketing products, for example) healthcare information source within the expertise of the writer. Clearly, if it takes 21 months and three providers to correctly diagnose hip pain, we must all be willing and able to ask questions of our healthcare providers (doctors, physical therapists, physicians assistants, nurses, hospitals, insurance companies).

$2.8 trillion ($2,800,000,000,000 – enough zeros?) is estimated to be spent on healthcare in 2013. In 2010, we spent just over $8000 per capita in the US and our life expectancy at birth ranks below countries that spend far less. Spain spends about $3000 per capita and has a life expectancy at birth of 82 and Japan spends $4000 per capita and has a life expectancy of 83.

Consider that the healthcare industry spent $5.36 billion lobbying Congress from 1998 to 2012 while the defense lobbyists spent $1.53 billion. Will this system change to your benefit as a patient? I do not think it will change in the near future and will thus continue to cost us all way more than we can afford.

I suggest we make the healthcare system challenges a mute point by using this reality as motivation to take charge of our own health. For example, what small lifestyle change can you make to start on the road to a healthier you today?

As a physical therapist I am partial to movement so why not move more each day. That means doing little things such as walking stairs, walking at lunchtime, taking family time and walking around your neighborhood after work with your kids, standing up from your office chair 10 times every two hours, anything you can think of that will increase your activity level.

A dietician may have ideas such as portion control, cutting out refined and fatty foods, eating more fruits and vegetables, drinking more water. All you dieticians out there, feel free to post your ideas of simple, easy ideas people can use to start the process of improving their health.

What about a wellness visit to your primary care doctor? Dr Ronald Hicks in Sparks, Nevada has been my primary care physician for almost 17 years. Every visit I have with him involves discussions about some form of healthy living (sun block, exercise, diet, stress), and I am a health person. He tells me he has many diabetic patients who do not control their blood glucose using simple dietary restrictions, exercise, regular montoring and medication use. I am floored by this. If we know what we need to do to control a disease which is potentially fatal, why do we not do it? (A lead into a future post maybe?)

In conclusion, at Custom Physical Therapy I have the priviledge of working with a variety of wonderful people all of whom have different needs. Everyday, there are people who can make small changes in lifestyle and thus have large gains in health. However, such lifestyle changes do not come easy and require motivation. With this post, I am suggesting we use the cost of healthcare as motivation to make the needed changes to become healthier. You will save on healthcare costs down the road as we will only use the expensive healthcare system when we truly need to. Prevention is the word.

YOUR TO DO LIST:

What one aspect of your lifestyle will you change today to start on the road to a healthier you?

Post your idea on this blog – I would love to read about it.

Send this post to someone you would like to join with on the quest to save $$$ by becoming a healthier you.

A study by Burnett et al in the Journal of Bone and Joint Surgery (2006) documented an average time from injury to accurate diagnosis for hip pain due to labral tears as 21 months. People with this type of hip pain saw an average of 3.3 providers before definitive treatment was initiaited. In 17% of their study group of 66 patients, surgery was recommended on a different anatomic site. Once the correct diagnosis was made and the hip arthroscopy was performed, 89% of the patients were clinically better off than before surgery. That is positive.

Hip pain can originate from a number of structures and as a result can be easily misdiagnosed. Low back pain can refer pain to the hip area. Sacroiliac joint dysfunction can too. Hip pain can be due to bony problems such as impingement or due to damage to the cartilage structure around the socket, that is the labrum (similar to the shoulder – see an earlier post on this blog). It can originate from strain or tearing of the lignaments around the hip joint as well as from all the many muscles which control the hip joint. In addition, pain may originate from the pubic area where the abdominal muscles and the hip adductors attach, commonly called athletic pubalgia or a sports hernia. Finally, hip pain can be a consequence of referred pain from the leg.

Hip pain is typically localized to the groin area. It may also be felt laterally over the outside of the hip or in the buttock. There may be clicking, popping and snapping in the hip joint associated with the pain. Walking, running, ascending and descending stairs, putting shoes on (figure 4 sitting) and lying on the affected side may be challenging.

Your to do list:

If you have back pain that radiates to the hip area (buttock, side of your leg, groin) ask your doctor or physical therapist to evaluate the hip. At Custom Physical Therapy we check the hip with every low back pain patient so we do not miss the diagnosis.

Educate yourself on the hip so you can ask questions of your doctor and physical therapist. Do not let your hip pain get misdiagnosed and take 21 months to be correctly treated.

Call us at Custom Physical Therapy if you have any questions regarding your hip pain. Mention you are calling with specific questions regarding this post on hip pain. We can answer your questions.

There are some really top notch hip doctors in Reno, Nevada. Call us if you want to know who they are.

Please forward this on to your friends, family and coworkers via email, Facebook, Twitter or word of mouth.

Thank you for being part of Custom Physical Therapy. Here’s to your healthy hips!

To my fellow Boomers out there ….. How are your knees doing? We are an active sector of the population and we want to remain that way for the health benefits (and the fun!) thereof. Knee pain due to osteoarthritis, whether one or both knees, has a dramatic impact on a person’s ability to continue with their chosen active lifestyle and, if it gets painful enough, may impact activities of daily living such as getting into and out of a car or a chair, cooking a meal or simply walking.

WHY KNEE OSTEOARTHRITIS?

Osteoarthritis affects 25 million North Americans and is symptomatic in 13% of people aged 55 years and older. It has been shown to be the most frequent cause of functional disability including being dependent on alternative forms of mobility due to the tremendous pain with walking. Ouch! The prevalence of osteoarthritis is rapidly increasing due to two main factors. Firstly, the aging of the American population (that includes us!) is increasing the share numbers of people older than 55 years. Secondly, the rapidly increasing obesity in our population is increasing the rate of joint degeneration. One study reported 83% of males who had knee osteoarthritis were obese compared to 42% of males without it. Wow! Now there is a statistic that says a lot and leaves nothing to the imagination as to what we need to do to address the issue.

WHAT IS IT?

Osteoarthritis is the joints response to structural damage caused by mechanical problems. It is the body’s attempt to repair a joint under unusual stress and often leads to a stable, pain free joint. If this process fails (is insufficient for the magnitude of mechanical stress placed on the joint) the knee becomes symptomatic and hence functionally debilitating.

Obesity increases the overall load through the joint and overwhelms the joint tissues resulting in osteoarthritis. Being bandy or bow-legged reduces the weight bearing surface area in the knee joints (shifts it from throughout the knee to one side or the other of the joint) and results in excessive wear and tear of the joint on the outer or inner surfaces respectively. Sustaining a serious injury to the knee in which ligaments are torn and the joint surfaces are banged together in the injury may initiate the osteoarthritic “repair” process as well. Thus, when stress on the joint tissues exceeds their physiological tolerance breakdown ensues and osteoarthritis begins.

HOW CAN WE ADDRESS THE CAUSATIVE FACTORS?

Weight loss in an effort to attain a normal body weight for your frame is paramount in reducing the forces through the knees. Walking results in a force through the knee equal to 3 – 4 times your body weight each step. If you lose 20 – 50 pounds in an effort to attain your normal weight, you reduce the forces through your knees by 80 – 200 pounds each step you take! Talk about happier knees! An 11.2 pound weight loss over a 10 year period has been shown to reduce the likelihood of developing knee osteoarthritis by 50%.

For misaligned knee joints (those of you who are bandy or bow-legged) there are unloading braces to modify (increase) the load bearing surface and hence reduce stress to the one side of the affected knee.

In all osteoarthritic knee joints muscle weakness, joint stiffness and poor balance are factors. Muscles around the knee joint serve to cause movement in bending and straightening the knee, can reduce mechanical stresses to the joint by absorbing loads applied to the limb (e.g. cushioning during landing a jump or when skiing) and stabilize the knee joint during daily tasks of walking, running, lifting and carrying to name a few. Patients with knee osteoarthritis are 20% to 40% weaker in their quadriceps than people without the condition. As the disease worsens the knee muscle activation patterns become less efficient and less specific and joint proprioception (the brain’s ability to know what is happening at the joint and react accordingly) is suppressed. A well constructed, evidence-based physical therapy program will improve strength, range of motion and proprioception and result in improvements in physical function, pain and quality of life. Modifying the mechanical problems causing the osteoarthritis together with addressing the inflammatory and pain aspects of the disease process through pharmacological intervention from your physician can result in an 86% success rate in improving your function. Who would not like that!?

All our physical therapists at Custom Physical Therapy have undergone specialized training for treating osteoarthritis. The therapists work as part of a team comprised of you the patient, your physician and the physical therapist. Using physical therapy interventions to modify the mechanical factors impacting the progression of osteoarthritis together with the physician addressing the pharmacological aspects and the patient being compliant with an exercise and stretching program (see our very first post on this blog) as well as brace use, if prescribed, the team of patient-physical therapist-doctor minimizes the effect of the disease process on your function.

YOUR CALL TO ACTION!

If you are overweight start a simple lifestyle change that entails weight loss (Call Joe Dibble, dietician at Sierra Strength and Speed, for a consult. He is really knowledgeable and practical.)

Call Custom Physical Therapy so we can evaluate your arthritic knees and set you up with appropriate treatment.

Forward this post to someone you know who has sore knees or you think may be interested in the information.

You are encouraged to call Custom Physical Therapy to talk to one of our accredited physical therapists about your knee pain. You may be a candidate for this customized evidence-based program specifically developed to improve your function which deteriorated due to knee osteoarthritis.

I really enjoyed Laura’s blogging of her total knee replacement. I think this is a great idea and one which can help other people who are potential knee replacement candidates get a sense of what the process looks like from a patient’s perspective.

Total joint replacements surgeries tend to increase towards the end of the year because insurance deductibles have been met and out-of-pocket expenses tend to be less. An additional cost to the patient is the rehabilitation after the surgery, which also tends to impact insurance deductibles.

The most frequent type of joint replacement that needs the most rehabilitation is the total knee replacement, also known as total knee arthroplasty (TKA). So what does the rehabilitation process involve?

The first thing to understand is that 50% of a successful outcome is the caliber of the surgery. If you have done your due diligence by being an educated healthcare consumer (see my very first post on this blog) and asked the best surgeon to do your total knee arthroplasty, you should be pretty confident that the actual prosthesis is the right size and was put in correctly. That is the easy part of the process; after all you slept through it!

Then you wake up and realize your knee hurts. It is swollen, stiff, and the muscles in your thigh (both quadriceps in the front and hamstrings in the back) do not contract well despite you attempting to make them to work. You have difficulty transferring from supine (lying on your back) to sitting and then to standing. Now you have to walk with a walker, another foreign experience. After 3-5 days, the doctor may send you home from the hospital. Now you need to get into the car to be driven home. This requires you to bend your new knee, another daunting thought. Once home you need to do the right thing to keep your progress going and prevent complications such as deep vein thrombosis (DVT: a blood clot) in either one of your legs, arthrofibrosis (excessive scarring from the surgery) and infection.

HELP!

Physical therapists now become your best friends and should be for a number of weeks to months following the surgery. You will be guided through a steady progression to return you to full function.

FIRST INPATIENT PHYSICAL THERAPY:

You will have inpatient physical therapy to get you ready for returning home i.e. avoid DVTs, know how to take care of your surgical wound and, you need to learn how to walk safely with a walker. You will also need to ascend and descend stairs, You should return home with enough active range of motion (AROM) to get into and out of the car and be instructed in transfers from supine to sitting to standing as well as how to get in and out of a chair. Detailed instruction should be given regarding how to control the postoperative swelling.

Surgical wound care: keep it dry, no showering – I have had one patient, 13 years ago, who decided to shower before the surgical wound was healed sufficiently. The knee became infected and was never the same again. Luckily it was not a TKA and the infection, therefore, did not enter the bone. It is worthwhile doing it right and accepting you will be a little dirtier than usual!

Walking: The majority of TKA patients start walking with a front wheel walker, day one or two after surgery. The large base of support gives the individual more stability. You must use an assistive device as your quadriceps (muscles comprising the front of the thigh) are not contracting efficiently. This is because of the incision and the pain impacting the function of the extensor mechanism (quadriceps + patella + patella tendon). As a result, you have difficulty straightening your knee and controlling it in full extension. When you transfer weight to the leg, the knee will have a tendency to give way (knee buckles under the weight) and you may fall.

Negotiating stairs with your walker: The inpatient physical therapist will teach you the correct technique for going up and down stairs with and without the walker. All homes have at least one to three steps to ascend from the garage to the house or at the front door. Just remember: the nonsurgical leg does all the work so you lead with it up stairs and lower your surgical side down with it when going down stairs.

AROM: Immediately you need to start working on getting your new knee straight (OUCH!) and getting it bending (OUCH!). The inpatient physical therapist should show you simple but effective exercises such as passive knee extension, hamstring and calf stretching to get it straight. They will also instruct you in heel slides to regain knee flexion. If you leave the hospital with full knee extension (straight knee) and 90° of flexion, you will be ahead of the game. With 90° of flexion you can get into and out of as well as sit in the car that will take you home.

Transfers: Inpatient physical therapists are the gurus at instructing in transfers under a variety of circumstances, all in an effort to get you more functional and independent. You should leave the hospital knowing exactly how to do a variety of transfers e.g. change positions in bed, sit to stand, in and out of a car, the commode, avoiding low chairs like a couch. You walker is your friend here to and you must focus on safety in all your mobility.

Control the swelling: This is a vital component of regaining full range and quadriceps function and should be a major focus immediately following surgery. (read the second post on this blog which discussed this topic in detail). Make sure you get iced in the hospital for 45 minutes at a time, all around your knee at least 4-6 times a day. You, the patient, must be vocal about this to get it done. You will be glad you followed this procedure. Recognize you will have bandages around your knee so it will take a while for the cold to penetrate them. Do not get the bandages wet (see paragraph above on infection!). Once the bandages are removed (7 to 10 days after surgery) you will ice for 30 minutes.

Now you are home. Feel better already, albeit a little beaten up I am sure. Out patient physical therapy now takes over. (if you are frail, you may get home health physical therapy but make sure they follow the following guidelines).

OUT PATIENT PHYSICAL THERAPY:

The other 50% of a good outcome is dependent on a good relationship between you and your physical therapists. Here is where the hard work really starts and you must be dedicated. Focus on the right things and you will get a great result.

Note: There is no need for the physical therapist to aggressively bend or straighten your knee. This may inflame the joint and increase the likelihood of arthrofibrosis. I typically set my patients specific goals to attain each week and it is their responsibility to achieve the range required. I measure at the beginning of each physical therapy session to track progress. If they struggle to improve at the agreed upon rate (typically 10° to 15° of active flexion per week), then I will step in and stretch their knee gently.

Rehabilitation is typically broken down into phases. Transition from one phase to the next is dependent on specific criteria such as degree of pain and swelling. Progression is not based purely on a timeline.

Phase 1: Post op days 1-10

Goals:

Understand the goals of the rehabilitation process.

Good pain control (pain less than 5/10)

Good control of swelling.

Can contract your quadriceps.

Can do a straight leg raise (SLR) with minimal lag (minimal loss of full knee extension when you raise your leg off the table while sitting).

Full passive extension (straight knee).

Active knee flexion 90°.

Independent gait and transfers.

Phase 2: Weeks 2 – 12 post-op

Goals:

AROM 0°-130° (we routinely are attaining 140° or more)

Mild joint effusion (swelling within the joint).

Can keep knee straight between physical therapy sessions.

Full SLR.

Normal gait pattern.

Independent in a suitable gym and/or home program based on specific individual needs of the patient at discharge.

So, there is a lot of work to do in recovering from a total knee replacement. It is not rocket science but it does require focused dedication. Focus on the right things based on your discussion with the physical therapist and be dedicated with your home exercises as well as those in the physical therapy clinic.

Your call to action:

If you are planning on a total knee replacement (or any other joint replacement) and have questions of any sort, call us at Custom Physical Therapy and a physical therapist will address your questions. Call 775-331-1199.

Forward this to a friend, family member or coworker who may be having a total knee replacement.

Forward this post to your physician and have them post a comment. It would be great to have their input too.

If you have had a total knee arthroplasty, please post a comment. People having knee replacements would benefit from hearing what worked and what challenges you faced during your recovery.

I am interested in how people decide where to go for their physical therapy. Let us know how you pick your provider and watch the results. Should be interesting. Knowing this information will help Custom Physical Therapy’s efforts to provide better services to our patients. Thanks for your efforts.

The goal of a pre-offer or post-offer pre-employment screen (PWS) is to mitigate risk in an effort to minimize workers compensation claims. In high risk jobs, those which cost your business the most in workers compensation claims due to higher injury rates, there are essential and critical job functions which can be tested prior to placing an employee in a position which may result in an injury.

Matching the right worker to the job is not a new concept, but has grown with the advent of companies concerned with providing an “Industrial Athlete” approach to the workplace – essentially ensuring that their employees are “game ready” and able to meet all challenges ahead of them. So, how should you proceed?

The first thing to do is decide if the pre-offer or post-offer screen should be used. The pre-offer pre-employment screen identifies the applicants who are physically able to safely complete the essential job functions of the position for which they are applying. It also will give you a baseline assessment of their physical abilities. If they do sustain an injury at work, this is the baseline physical ability to which they will be rehabilitated too. A post-offer pre-employment screen performs the same function but you can include a medical examination too. The advantage of a post-offer over the pre-offer screen is that you can ascertain if the applicant you have offered the job to contingent on passing the PWS has any disability (e.g. are they under physical limitations by a physician due to a prior injury). The functional test has a significant advantage over just doing a medical screen, as an employee may not choose to report a pre-existing condition. The functional test will uncover and thus document this unreported inability to perform tasks if their pre-existing condition is deemed a hindrance to performing the job demands.

Now your company must identify the high risk jobs within your business. High risk jobs are those which are simply physically difficult to perform. They are not easily modifiable to the employee nor are they easily changed to improve safety. Hence, the employee must be fitted to the demands of the job. These jobs historically may include heavy lifting, highly repetitive functions or aerobic activities. Is there a manufacturing or laborer position which results in a larger proportion of your workers compensation costs? Do you have musculoskeletal injuries occurring in a particular type of worker in a production line? Is there a high turnover rate for a particular position at your business? Are there employees who are physically taxed during the work day (sweating, out of breath, unusually fatigued) and hence avoid doing the more challenging aspects of their job by giving it to the newer, younger employees? If you have a “Yes” to the above questions, your business should be performing pre/post-offer pre-employment screens on these specific high risk employees as part of the selection process.

The next step is to develop a well-constructed, objective, accurately measured job demands analysis (JDA) for each high risk job you identified. This entails evaluating the job to ascertain the essential and nonessential tasks and objectively quantifying them. This process involves close teamwork between the employer, the physical therapist performing the JDA and worker representatives. Teamwork such as this produces a JDA that accurately reflects the high risk job functions and will comply with the American with Disabilities Act and the U.S. Equal Employment Opportunity Commission laws. Not only is the JDA used for PWS design, it is also used in rehabilitating any injured workers. The JDA should be used by the physical therapist treating your injured worker to design the rehabilitation program based on essential job functions listed in the JDA. In addition, the physical therapist will be able to clearly ascertain if the employee is ready for a safe and most importantly a sustained return to work. This same JDA becomes the foundation for any Fit for Duty testing, Job Transfer or post injury evaluation job placement.

Utilizing the JDA, the PWS is then developed by the physical therapist. It tests the essential job functions prior to placing the employee in the high risk position. The final PWS will involve combinations of lifting, pushing, pulling, carrying, ladder climbing, overhead arm use, cranking, kneeling, crawling and any other essential job functions specific to the job in which the employee will be placed on passing the test. All tasks will have a critical cadence which must also be assessed to place these tasks in a physical demands category: sedentary, light, medium, heavy or very heavy. Job specific weights will thus be lifted to job specific heights at job specific critical cadences. Job specific weights will be pulled or pushed for job specific distances. It is important that all tasks tested in the PWS are absolutely specific to the job. All tests in the protocol have to have a solid foundation of evidence supported by peer-reviewed and published papers to validate a proper extrapolation to a full eight hour workday.

Is this a cost-effective program for your business?

Consider the following savings reported by companies who utilize this approach:

Lear Seating performed 104 PWS in a year. Thirty percent of applicants failed the test indicating they were unfit to complete the demands of the high risk job. Total Savings: $2,073,000.

A frozen foods company reduced their musculoskeletal injury rate by 41.7%. Total Savings: $5,153,500. Return on investment: 3:1.

Considering the average cost of industrial injuries ($13 to $15 billion annually for musculoskeletal disorders), setting up a program to limit injury rates and hence workers compensation premiums is a good idea for any company which has high risk jobs.

By matching physically suitable employees to the appropriate high risk jobs you are mitigating risk, reducing lost time and thereby improving productivity and yielding a better bottom line through a healthier workforce.

André Meintjes, M.P.T., C.F.E.,Ph.D. is a physical therapist and owner of Custom Physical Therapy in Sparks and Reno, Nevada. Contact him at 775-331-1199 or ameintjes@usphclinic.com.

Tendinitis is the inflammation of a tendon and of tendon-muscle attachments i.e. where the tendon attaches to the bone (insertional tendinitis). It is an overuse phenomenon, can be excrutiatingly painful and functionally debilitating. Treatment should focus on addressing the cause of the tendinitis, reducing the inflammation and the pain, and remodelling the tendon through a controlled exercise progression.

Most frequently seen diagnoses in our physical therapy clinic are rotator cuff tendinitis (supraspinatus tendinitis), posterior tibial and peroneal tendinitis (pain in the foot and ankle), tennis elbow (lateral epidondylitis), achilles tendinitis, patella tendinitis and iliotibial band syndrome. Interestingly, we have recently been seeing an increase in tendinitis of the guteus medius (hip abductor muscle). We see golfer’s elbow (medial epicondylitis) less frequently than tennis elbow.

Despite tendinitis occuring in tendons all over the body, the approach to treating the condition remains the same for each structure involved. You treat the tendonitis by following a specific intervention progression. The exercises are different for the different tendons but the principle remains the same:

Treat the cause of tendinitis.

It does not matter what tendon is involved, the cause is most frequently overuse. Overuse means the stress the tendon has had to endure, as a result of the force it is being asked to apply (both intensity and frequency), results in microtrauma to the tendon structure and hence inflammation. If the tendon is not given rest, it does not have the opportunity to recover. Examples of activities which can result in tendinitis include typing, repeated gripping on a production line, fly fishing, overhead lifting or repeated jumping. Ankle sprains may cause tendinitis in the posterior tibialis and peroneal tendons of the foot.

So, the first line of attack is to decipher what the causative activities are and modify them. For most rapid resolution, these should be stopped completely to avoid the continuous trauma to the tendon. Sometimes this is not possible and a program of relative rest must be designed by the physical therapist:patient team.

Treat the inflammation.

Part of controlling the inflammation is reducing the stress on the tendon. The physical therapist will address this with you in detail. As mentioned above, rest gives the tendon the opportunity to recover from the microtrauma (as noted above). Non-steroidal anti-inflammatories or even streroids may be prescribed by your physician at the same time. Physical therapy interventions to control inflammation include ice in the form of an ice pack or even ice massage and, iontophoresis – the administration of an anti-inflammatory, dexamethazone, to the tendon utilizing electrical currenct to faciltiate the passage of the medication through the skin (Yes! No needles!).

Treat the pain.

By following the above suggestions, pain should subside over time as the inflammation is controlled. If the pain is severe enough your physician may subscribe analgesics (pain killers).

Remodel the tendon.

Here is where the work is! Your physical therapist will teach you how to stretch the involved tendon as well as progress you through a specific exercise regimen which involves both concentric and eccentric exercises which will stress the tendon. A concentric exercise is one in which the muscle contracts and shortens at the same time e.g. the bicep contracts to bend the elbow bringing the coffee cup to your mouth. An eccentric contraction is one in which the contracting muscle is lengthening while it contracts e.g. the bicep contracts and lengthens as it controls the extending elbow to put the coffee cup back down on the table. An eccentric contraction places more tension on the tendon than a concentric contraction and can thus promote tendon remodelling. Eccentric exercises are more aggressive than the concentric type.

The goal of the stretching and strengthening progression is to stimulate tendon remodelling. This improves the flexibility and tensile strength of the tendon. This, in turn, improves the tendons ability to tolerate the original activity which caused the tendinitis.

Soft tissue mobilization? Deep transverse friction?

What about soft tissue mobilization and deep transverse friction? Soft tissue mobilization of the involved muscle belly and, indeed, of the surrounding musculature can be helpful in alleviating discomfort. It is less aggressive than deep transverse friction and is definitely more comfortable.

Deep transverse friction is used to stimulate blood flow in the involved tendon and break up any adhesions which may have developed as a consequence of the microtrauma of the tendinitis. It is done by applying significant pressure (up to 7/10 pain) over the tendon with the thumb or index finger and rubbing in a direction transverse to the direction of the tendon fibers. Sound like fun!? It is done in conjunction with the tendon remodelling exercises detailed above.

YOU CALL TO ACTION:

Make sure you visit us early on in the process because it is much easier to treat than if you have had tendinits for more than a few weeks. EARLY INTERVENTION!

Make sure you specifically ask to be sent to physical therapy the very first visit you have with your doctor so you can be shown the specific exercises and enjoy the hands-on treatment from the physical therapist.